Provider Demographics
NPI:1881138469
Name:PHARMACY AT ABACOA, INC.
Entity type:Organization
Organization Name:PHARMACY AT ABACOA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIVAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-349-6800
Mailing Address - Street 1:PO BOX 912
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33468-0912
Mailing Address - Country:US
Mailing Address - Phone:855-349-6800
Mailing Address - Fax:855-349-6801
Practice Address - Street 1:1155 MAIN ST STE 109
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-5264
Practice Address - Country:US
Practice Address - Phone:561-900-3770
Practice Address - Fax:561-900-3771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-15
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166791OtherPK